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. 2023 Jul 12;11(7):1973.
doi: 10.3390/biomedicines11071973.

Evaluation of Fine Needle Aspiration Cytopathology in Salivary Gland Tumors under Milan System: Challenges, Misdiagnosis Rates, and Clinical Recommendations

Yi-Tien Huang  1 , Chen-Yu Ho  1 , Chun-Yen Ou  1 , Cheng-Chih Huang  1 , Wei-Ting Lee  1 , Shu-Wei Tsai  1 , Heng-Jui Hsu  1 , David Shang-Yu Hung  1 , Chien-Sheng Tsai  1 , Sheen-Yie Fang  1 , Sen-Tien Tsai  1 , Jenn-Ren Hsiao  1 , Chan-Chi Chang  1 , Chien-Chin Chen  2   3   4   5
Affiliations

Evaluation of Fine Needle Aspiration Cytopathology in Salivary Gland Tumors under Milan System: Challenges, Misdiagnosis Rates, and Clinical Recommendations

Yi-Tien Huang et al. Biomedicines. .

Abstract

(1) Background: Salivary gland tumors are rare in the head and neck. To determine the need and extent of surgical intervention, fine needle aspiration (FNA) is a widely accepted tool to approach salivary gland lesions. However, the FNA cytology varies between entities, while the lack of uniform terminology makes diagnosis more challenging. Since establishing the Milan system for reporting salivary gland cytopathology (MSRSGC) has become an increasingly accepted reporting standard, further examination and detailed recommendations were needed. (2) Methods: Between April 2013 and October 2021, 375 cases with FNA and salivary gland resection were retrospectively collected. All FNA specimens were reclassified according to the criteria of MSRSGC. After surgical excision, the FNA data were compared with the histological diagnosis to estimate the risk of malignancy (ROM), the risk of neoplasm (RON), and the diagnostic accuracy for each diagnostic category. (3) Results: Our cohort's distribution of ROM and RON was similar to the MSRSGC's recommendation. Carcinoma ex pleomorphic adenoma (CXPA) has the highest rate (66.7%) of misdiagnosed as a nonneoplastic lesion or benign salivary gland tumor. Pleomorphic adenoma (PA) and Warthin's tumor were the most common benign salivary gland tumors, while the cytology diagnosis of Warthin's tumor seems more challenging than PAs. (4) Conclusions: Despite the convenience and effectiveness of MSRSGC, we suggest close follow-up, re-biopsy, or surgical removal for salivary lesions even in Milan IVA-Benign for possibly missing FNA of malignancy, mixed lesions, or prevention of malignant transformation.

Keywords: FNA; MSRSGC; Milan system; Warthin’s tumor; benign neoplasm; cytopathology; fine-needle aspiration; pleomorphic adenoma; salivary gland.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
The discrepancy between fine needle aspiration (FNA) diagnosis and histology in different malignant salivary gland tumors. Milan II-NN and Milan IVA-Benign were defined as negative results, while Milan V-SM and Milan VI-M were positive. Abbreviations: Milan II-nonneoplastic (NN), Milan III-atypia of undetermined significance (AUS), Milan IVA-benign neoplasm (Benign), Milan IVB-salivary gland neoplasms of unknown malignant potential (SUMP), Milan V-suspicious for malignancy (SM), Milan VI-malignant (M), acinic cell carcinoma (ACC), squamous cell carcinoma (SCC), adenoid cystic carcinoma (AdCC), secretory carcinoma (SC), salivary duct carcinoma (SDC), adenocarcinoma not otherwise specified (AC-NOS), mucoepidermoid carcinoma (MEC), carcinoma ex pleomorphic adenoma (CXPA).
Figure 2
Figure 2
The histology distribution for the Milan IVB-SUMP of salivary gland FNA.
Figure 3
Figure 3
(A) Distribution of pleomorphic adenoma among the Milan system for reporting salivary gland cytopathology diagnostic categories (MSRSGC) and its anatomical location; (B) Distribution of Warthin’s tumor among MSRSGC diagnostic categories and its anatomical location.
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